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Submicroscopic Infection in Plasmodium falciparum –Endemic Populations: A Systematic Review and Meta‐Analysis
Abstract
INTRODUCTION: Light microscopy examination of blood slides is the main method of detecting malaria infection; however, it has limited sensitivity. Low-density infections are most likely to be missed, but they contribute to the infectious reservoir. Quantifying these submicroscopic infections is therefore key to understanding transmission dynamics and successfully reducing parasite transmission. METHODS: We conducted a systematic review of endemic population surveys in which P. falciparum prevalence had been measured by both microscopy and a more-sensitive polymerase chain reaction (PCR)-based technique. The combined microscopy:PCR prevalence ratio was estimated by random-effects meta-analysis, and the effect of covariates was determined by meta-regression. RESULTS: Seventy-two pairs of prevalence measurements were included in the study. The prevalence of infection measured by microscopy was, on average, 50.8% (95% confidence interval [CI], 45.2%-57.1%) of that measured by PCR. For gametocyte-specific detection, the microscopy prevalence was, on average, 8.7% (95% CI, 2.8%-26.6%) of the prevalence measured by PCR. A significantly higher percentage of total infections was detected by microscopy in areas of high, compared with low, transmission (74.5% when the prevalence determined by PCR was >75% versus 12.0% when the prevalence determined by PCR was <10%). DISCUSSION: Microscopy can miss a substantial proportion of P. falciparum infections in surveys of endemic populations, especially in areas with low transmission of infection. The extent of the submicroscopic reservoir needs to be taken into account for effective surveillance and control.
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“Over the past decades, several studies have demonstrated submicroscopic P. falciparum infection, detectable only by sensitive molecular (PCR) methods in Sub-Saharan Africa (SSA) and documented high prevalence rates of low-density parasitaemia, shedding new light on the real prevalence of malaria infections [11], especially in pregnant women [2].”
From Intermittent preventive treatment with Sulphadoxine-Pyrimethamine (IPTp-SP) is associated with protection against sub-microscopic P. falciparum infection in pregnant women during the low transmission dry season in southwestern Cameroon: A Semi - longitudinal study (2022) · cites this paper as [11]
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“Between these two extremes, there was an inverse relationship between the proportion of submicroscopic infections and the transmission intensity (by PCR prevalence).”
From What is the burden of submicroscopic malaria in pregnancy in central India? (2015) · cites this paper as [5]
In the citing paper
“A meta-analysis of surveys conducted in endemic areas reported that 88% of all infections went undetected by microscopy in areas of low transmission compared to only 25.5% in areas of high transmission. 5”
From What is the burden of submicroscopic malaria in pregnancy in central India? (2015) · cites this paper as [5]
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Bousema, T., & DRAKELEY, C. J. (2011) · Clinical Microbiology Reviews · doi:10.1128/cmr.00051-10 · Cited by 776
Self-citationThe changing epidemiology of malaria elimination: New strategies for new challenges
Cotter, C., Sturrock, H. J., Hsiang, M. S., Liu, J., Phillips, A. A., Hwang, J., Gueye, C. S., Fullman, N., Gosling, R. D., & Feachem, R. G. (2013) · The Lancet · doi:10.1016/s0140-6736(13)60310-4 · Cited by 671
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Self-citationThe silent threat: asymptomatic parasitemia and malaria transmission
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Metadata
- Authors
- Okell, L. C., Ghani, A. C., Lyons, E., & Drakeley, C. J.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- Imperial College London (GB)
- Corresponding author
- Okell, Lucy C.
- Venue
- The Journal of Infectious Diseases
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-11-15
- Volume
- 200
- Issue
- 10
- Pages
- 1509-1517
- ISSN
- 0022-1899 (ISSN-L)
- 1537-6613
- OpenAlex
- W2125263196
- Cited by
- 532
- References
- 158
- Citations by year
- 2026: 13 · 2025: 26 · 2024: 21 · 2023: 24 · 2022: 30 · 2021: 38 · 2020: 39 · 2019: 36 · 2018: 34 · 2017: 39 · 2016: 43 · 2015: 46 · 2014: 34 · 2013: 40 · 2012: 30
- FWCI
- 3.03
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Infectious Diseases (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Wellcome Trust
- Medical Research Council
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Malaria Research and Control
- Life Sciences › Immunology and Microbiology › Parasitology › Bird parasitology and diseases
- Health Sciences › Medicine › Genetics (clinical) › Hemoglobinopathies and Related Disorders
- Keywords
- Plasmodium falciparum, submicroscopic malaria infection, malaria prevalence, PCR detection, gametocytes, infectious reservoir, transmission intensity, malaria surveillance, endemic populations
- MeSH terms
- Disease Reservoirs, Humans, Prevalence, Polymerase Chain Reaction, Malaria, Falciparum, Endemic Diseases
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